The Medium-Run and Scale-Up Effects of Performance-Based Financing: An Extension of Rwanda’s 2006 Trial Using Secondary Data

Objective: To extend the initial evaluation of Rwanda’s performance-based financing program in order to identify medium-run and scale-up effects of incentives and unconditional financing relative to one another and a new “business as usual” counterfactual. Methods: We use secondary data from the Demographic and Health Surveys from Rwanda and its East African neighbors from 2001 to 2010. We identify a relevant set of controls using neighboring regions that are similar to Rwanda based on pre-intervention trends in covariates and outcomes. We then use difference-in-differences regressions to measure the program’s impacts on key maternal health service indicators. Findings: In the first two years and relative to no intervention, performance-based and unconditional financing raised institutional delivery rates by 21 and 13 percentage points, respectively, and performance-based financing increased completion of four antenatal visits by 6 percentage points. After two years, relative to no intervention and in addition to the initial short-run impacts, performance-based incentives resulted in further improvements of 11 percentage points for institutional deliveries and 10 percentage points for completion of four antenatal visits. Program scale-up was effective, with no differences between intervention arms after all areas received performance-based incentives. We find few effects on antenatal tetanus prophylaxis. Conclusions: Rwanda’s performance-based incentives were effective for some indicators, but unconditional financing also induced improvements. The incentive effects persisted in the mediumrun and as the program was scaled-up. Additionally, the analysis demonstrates how observational research methods and secondary data can generate new insights on existing evaluations.